Safer Solutions: Smoking Hits an All-Time Low—But Not for Everyone

In 2024, smoking among U.S. adults fell below 10 percent for the first time in recorded history—an achievement that should be celebrated. But that big-picture number masks another reality: As smoking plummets overall, smoking rates remain stubbornly high in many marginalized and vulnerable communities. This is true for people with mental illness, people who experience discrimination, people living with HIV, veterans, people living in poverty, and more. The complex factors that make it so hard for some people to quit smoking remind us there is no one-size-fits-all approach to smoking cessation. Instead, innovation, flexibility, and an “every tool in the toolbox” approach are needed to give people who smoke every possible chance to quit successfully.

Overlapping Challenges and Stubbornly High Smoking Rates

People’s reasons for picking up smoking (and for continuing to smoke) are individual and complex—often a mix of “physiological, psychological, and behavioral components.” People can become physically dependent on the nicotine found in tobacco, but there are other elements to smoking addiction as well:

• Situational (e.g., having a cigarette with a morning cup of coffee)
• Social (e.g., spending time with a friend group where everyone smokes)
• Emotional (e.g., coping with stress)
• Habitual (e.g., lighting a cigarette and inhaling smoke thousands of times per year)

Mental health and smoking have a complex and sometimes mutually reinforcing, bidirectional relationship. While smoking “may be an attempt to self-medicate,” it can cause or exacerbate mental health symptoms over time. Conversely, quitting smoking is associated with improved mental health. Smoking rates among people with depression and anxiety or attention-deficit/hyperactivity disorder are double that of the general population, and rates among people with schizophrenia are as high as 85 percent. Post-traumatic stress disorder (PTSD) is associated with high smoking rates and “one of the lowest [quit rates] of all mental disorders.” PTSD plays a role in lower quit rates among military veterans, too. Veterans exhibit higher rates of PTSD than the general population and might be impacted further by the culture of smoking in the military as well as the stressors of service and return to civilian life.

Discrimination is also associated with higher smoking rates. Here, too, mental health has an overlapping role. People who experience exclusion or hostility due to their race or ethnicity return to smoking at higher rates after a quit attempt compared to the general population. Smoking prevalence among Black Americans is much higher among those who experience frequent discrimination, while “minority stress” correlates with smoking disparities among LGBTQ+ people.

Smoking rates are higher among people living below the poverty line as well. A circumstance characterized by “multiple physical and psychosocial stressors,” poverty collides with discrimination for many people who smoke, including people living with HIV. The U.S. HIV epidemic is “closely enmeshed in conditions of poverty.” People with HIV are nearly twice as likely to smoke and much less likely to quit than the general population—meaning that Americans living with HIV now lose more years of life to smoking than to HIV itself.

Of course, these and other stressors and disadvantages can overlap; in fact, researchers have found that smoking rates increase further with each additional disadvantage people face.

Leaving No One Behind, Meeting People Where They Are

As we celebrate progress in smoking cessation, how can we ensure that populations with persistently high smoking rates are included in this progress? Can we cast a wider net to make more quitting options available and accessible to people who smoke?

Traditional approaches to smoking cessation—including counseling, nicotine replacement therapy, and Food and Drug Administration (FDA)-approved medications—remain important. We must continue to improve access to these tools, especially for populations affected by higher smoking rates; however, these tools alone leave too many people behind.

Research on psychedelics for smoking cessation is showing some promise, and some state legislatures are considering policy reforms that would allow for the production and administration of these drugs. Meanwhile, other new therapeutic approaches—including the plant-derived cytisinicline, GLP-1 drugs, transcranial magnetic stimulation, and virtual reality “digital therapeutics”—are moving through clinical trials.

While we wait for more evidence on these potential new therapies, non-combustible nicotine products like e-cigarettes offer a harm reduction approach with a robust evidence base. These products deliver nicotine with significantly fewer cancer-causing chemicals than those found in tobacco smoke while preserving some of the behavioral, ritualistic, and social elements that contribute to smoking’s appeal. A complete switch from smoking to these reduced-risk products is “quitting smoking,” too; in fact, evidence shows that this approach results in higher quit rates compared to traditional methods. Unfortunately, these tools are too often stigmatized within communities and by public health organizations.

Conclusion

If we truly aim to include everyone in the historically low rates of smoking in America, we must acknowledge the complexities of smoking and its disparate impacts on vulnerable populations, and support access to more tools and resources that meet people who smoke where they are. That will be something to celebrate, too.